Pulseless Electrical Activity Research Articles

Demonstration of Doppler Ultrasound Pulse Detection by Trained Prehospital Personnel

Background and Aim: Data suggests that finger palpation of the carotid and/or femoral pulses is significantly less sensitive than 100%. In some cases, a patient who does, in fact, have organized cardiac function, may be identified as being in Pulseless Electrical Activity (PEA). Chest compressions performed as indicated by these circumstances may not provide significant therapeutic benefit to those patients and may, in fact, distract from better directed therapies. Doppler Ultrasonography (DUSG) has been shown to be more sensitive than human fingers. This research aims to assess whether EMT-Basics and Paramedics can be quickly and inexpensively trained to use DUSG as a tool for pulse detection. Methods: Participants viewed a recorded video 4 minutes 18 seconds in length which detailed an anterior-to-posterior fanning technique for assessing presence of a carotid pulse using a doppler ultrasound device. The participants were given a short period of time to practice and familiarize themselves with the device. Participants were then timed while demonstrating application of ultrasound-conducting gel to a volunteer and using the device to detect a carotid pulse. The time recording ceased when the participant verbalized confirmation of the pulse, and their success or failure was annotated. Results: Credentialed EMT-Basics and Paramedics, with minimal training, consistently demonstrated the ability to accurately and rapidly assess a carotid pulse using a doppler ultrasound device. Conclusions: This research suggests that prehospital personnel can be efficiently trained to use available and inexpensive doppler ultrasound devices to determine cardiac pulse status. Furthermore, it suggests that the technique itself can be used to detect the carotid pulse quickly and accurately. Further research in patient care settings should be undertaken to evaluate the utility of doppler ultrasound devices in distinguishing PEA from Pseudo-PEA.

Association Between QRS Characteristics in Pulseless Electrical Activity and Survival Outcome in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

Objective Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm. Methods Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. Results A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11–3.11, I 2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19–3.02, I 2 = 65%). Conclusions Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.

Assessing feasibility of proposed extracorporeal cardiopulmonary resuscitation programmes for out-of-hospital cardiac arrest in Scotland via geospatial modelling

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) can improve survival for refractory out-of-hospital cardiac arrest (OHCA). We sought to assess the feasibility of a proposed ECPR programme in Scotland, considering both in-hospital and pre-hospital implementation scenarios. MethodsWe included treated OHCAs in Scotland aged 16–70 between August 2018 and March 2022. We defined those clinically eligible for ECPR as patients where the initial rhythm was ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity, and where pre-hospital return of spontaneous circulation was not achieved. We computed the call-to-ECPR access time interval as the amount of time from emergency medical service (EMS) call reception to either arrival at an ECPR-ready hospital or arrival of a pre-hospital ECPR crew. We determined the number of patients that had access to ECPR within 45 min, and estimated the number of additional survivors as a result. ResultsA total of 6,639 OHCAs were included in the geospatial modelling, 1,406 of which were eligible for ECPR. Depending on the implementation scenario, 52.9–112.6 (13.8–29.4%) OHCAs per year had a call-to-ECPR access time within 45 min, with pre-hospital implementation scenarios having greater and earlier access to ECPR for OHCA patients. We further estimated that an ECPR programme in Scotland would yield 11.8–28.2 additional survivors per year, with the pre-hospital implementation scenarios yielding higher numbers. ConclusionAn ECPR programme for OHCA in Scotland could provide access to ECPR to a modest number of eligible OHCA patients, with pre-hospital ECPR implementation scenarios yielding higher access to ECPR and higher numbers of additional survivors.

OUTCOMES OF OUT HOSPITAL CARDIAC ARREST: SEX DISPARITIES IN OUR REGION

Abstract Background The incidence of out of hospital cardiac arrest (OHCA) differs consistently between women and men.Besides sex related factors, OHCA risk may relate to gender related factors.Although previous studies regarding sex difference outcomes after OHCA yielded conflicting results, from some researches it seems that women have less shockable initial rhythm than men and they have worse survival. Methods We considered 5524 consecutively OHCA survivors resuscitated from emergency medical System (EMS) or bystander In two city of Emilia Romagna: Piacenza (3452 ) and Bologna (2072) from January 2009 to December 2019 and we evaluated the outcomes, considering sex and gender disparities. Results Out of 5524 patients, who experienced OHCA, 3340 (60%) were males with average age 70,6 ±14 years and 2184 (40%) females with average age of 78,9 ±13 years (p&amp;lt;0,001).Overall survival rate was 8% .In our population we observed as initial rhythm of cardiac arrest : 3057 (57%) asystole, 1070 (22%) ventricular fibrillation (VF) and 998 (21%) pulseless electrical activity (PEA) with sex disparities.In fact we have found : 1695 asystole (51%), 840 FV (25%), 583 pea (17%) in men and 1362 asistolia (62%), 230 fv (11%), 415 pea (19%)in women. Asystole was more frequently in females (62 f vs 51m %, p&amp;lt;0.001), whilst VF in males (25 vs 11%, p&amp;lt;0.001).Furthermore considering sex disparities, survival was better in males 299 (9%) than in females 115 (5%), p&amp;lt;0.001. Conclusions In our population OHCA was more frequent in males in line with previous published data. However, females affected by OHCA are older, tend to present more frequently with non–shockable rhythms and show worse outcome. It’s unknown if these data are related to sex biological differences or gender disparities . Further data will be necessary to explain this challenge.

VASOSPASTIC INFARCTION STARTED WITH PULSELESS ELECTRICAL ACTIVITY CARDIAC ARREST

Abstract We report the case of a 48–year–old female with a special history of ischemic heart disease. It started in 2021 with an acute anterior ST myocardial infarction: the coronary angiography showed subocclusive stenosis at the first tract of the left anterior descending (LAD), without other coronary stenoses. The patient was treated with primary PCI + DES; the echocardiogram showed EF 30% and akinesia of apex, intermediate segments of anterior wall and interventricular septum. During the same hospitalization the patient experienced recurrence of angina with transient ST elevation in the anterior and inferior leads; a control coronary angiography was unchanged. She was started on therapy with nitrates and diltiazem up to the tolerated dose, statin as well as antiplatelet and anticoagulant therapy due to apical thrombus. She underwent ICD implantation in primary prevention in January 2022. During 2022, there were several accesses to the ED for vasospastic angina despite medical therapy at the maximum tolerated dose. In October 2023 the patient experienced an acute chest pain followed by cardiac arrest, pulseless electrical activity and acute cardiogenic shock. After resuscitation procedures, she underwent an emergency coronary angiography which showed excellent result of the previous PCI, as well as stenosis of the distal edge of the stent resolving after injection of i.c. nitrates. No arrhythmic events at ICD recording and continuous electrocardiographic monitoring in ICU were observed. Cardiac MRI showed areas of subendocardial LGE involving the apex, anterior, anterolateral and septal segments due to ischemic scar; we also observed areas of edema and LGE with an ischemic pattern at the infero–septal and inferior wall in toto, suggesting recent ischemia; EF was 31%. During hospitalization the patient experienced episodes of typical angina with poor response to medical therapy at the maximum tolerated dose. The current clinical case most likely points to acute myocardial infarction due to vasospasm of the right coronary artery with acute pump failure resulting in cardiac arrest and no specific recommendations exist in recent cardiologic guidelines on the strategy to adopt for this acute clinical setting. In the hypothesis of a vasospastic pathogenesis of the problem, counseling for modulation of the stellate ganglion was requested.

OUTCOME OF OUT OF HOSPITAL CARDIAC ARREST: ARE THERE GENDER DIFFERENCES?

Abstract Background Despite advance in resuscitation science, out of hospital cardiac arrest (OHCA) has an average survival rate of only 10 %. Ventricular fibrillation (FV) is amenable to defibrillation, but deteriorates to non shockable rhythms over time. It’Known that immediate cardiopulmonary resuscitation and eraly defibrillation increase survival after OHCA. It remains unclear whether there is an association between gender and survival. It seems that women OHCA patients are older, are less likely to have a witness arrest and they had fewer arrest in pubblic location than men . However these data are controversial. Methods We considered consecutively 6995 OHCA survivors resuscitated from emergency medical System (EMS) or bystander (BS) In Piacenza between june 1999 to decembre 2022 and we evaluated the outcome, considering sex and gender disparities Results Out of 6995 suffered from OHCA, 2983 (43%) were females with average age 81 ±13 years and 4012 (57%) males with average age of 73 ±15 years (p&amp;lt;0,00001).We observed with advanced age an incresead rate of woman that suffered from OHCA in comparison to man (&amp;lt; 44 years 177 m vs 63 w; 45–60 y 594 m vs 152 w, 61–75 y 1261m vs 530w; &amp;gt; 75 y 1980 m vs 2239 w).The survival of our population was 270 patients At EMS arrival 6150 patients (88%), 2779 (45%) female and 3371 (55%) male presented a non schockable rhythms (NSR):asystole or pulseless electrical activity (PEA) whilst 845 patients(12%), 170(75%) males and 56 (25%) females, presented FV .In the group with FV as initial rhythm, the survival was 26% (56/206 f 27% vs 107/647 m 26% p= 0,06). Also in this group women were slightly older (73 years f vs 67 m, p&amp;lt;0,00001). In all population survival decreased in females vs males (66/2984 w 2% vs 200/4012 5%f vp&amp;lt;0,00001).Females appeared with more non schockable rhythms (93 % f vs 84 % m, p&amp;lt; 0,00001)Women suffered from OHCA were found more frequently at home (2785 w 93% vs 3379 84%m p &amp;lt; 0,0001).Furthermore 97% males and 98% female were treated by EMS and 3 % males and 1,3% females by BS(survival males 3,6% EMS vs 51% BS and females 2 EMS%vs 26%BS). Conclusions In our OHCA population, the survival was 4% with better results in man Female were older and they had less survival, because initial rhythm registered were non shockable rhythms. They were found at home,with a delay in the first aid. This can be due to a gender disparities with advanced age.

Rising from the Abyss: Exploring the Lazarus Effect in Post-cardiac Arrest Spontaneous Resuscitation

Autoresuscitation refers to the heart's ability to spontaneously regain activity and restore circulation, a concept first elucidated by K. Linko in 1982 following discontinued cardiopulmonary resuscitation (CPR). J.G. Bray coined the term "Lazarus phenomenon" in 1993, drawing from the biblical account of Lazarus being resurrected by Jesus four days after his death. By the end of 2022, 76 cases of spontaneous recovery after death had been documented worldwide, with 10 cases involving children. The range of patients spanned from a 9-month-old infant to a 97-year-old individual. Resuscitation efforts varied in duration from 6 minutes to a maximum of 90 minutes, occurring both within and outside medical facilities. Many patients had underlying health conditions, and the majority experienced non-shockable rhythms (such as Asystole or Pulseless Electrical Activity) during cardiac arrest. Survival periods post-resuscitation ranged from minutes to months, with six patients achieving full recovery without neurological deficits. Various factors contributing to autoresuscitation include hyperventilation-induced alkalosis, auto-PEEP, delayed drug effects, hypothermia, intoxication, metabolic disorders like hyperkalemia, and undetected minimal signs of life. To prevent Lazarus Syndrome, it is advised to monitor patients for at least 10 minutes after halting CPR. Raising awareness of this phenomenon within the medical community is crucial for enhancing case reporting. The likelihood of autoresuscitation appears feasible, especially among older individuals.

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists. In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures. The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services

BackgroundSeverity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm.MethodsWe conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets.ResultsAfter exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023).ConclusionsBased on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study

BackgroundThe likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients.MethodsThe ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18–50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months.DiscussionThe ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment.Trial registrationClinicaltyrials.gov under NCT04620070, registration date 3 November 2020.

Cardiac arrest after severe epistaxis

Nasal bleeding frequently leads to admissions to the Emergency Department (ED), with anterior nasal packing being a common treatment approach. Our patient was transferred to the ED from a nursing home due to epistaxis, which was already initially managed by nasal packing. Upon arrival at the ED he suffered Cardiopulmonary Arrest (CA) with an initial CA rhythm of Pulseless Electrical Activity (PEA). Advanced Life Support (ALS) was initiated immediately according to the ERC guidelines. Upon intubation, a nasal gauze was aspirated from the endotracheal tube, and approximately ten minutes later, Return of Spontaneous Circulation (ROSC) was achieved. Subsequently, the patient was transferred to the Intensive Care Unit (ICU). Unfortunately, despite medical intervention, the patient succumbed to complications days later. The dislodgement of nasal packing leading to asphyxiation represents a rare but potentially fatal complication of this procedure. Healthcare providers should be vigilant and prepared to promptly address such complications as they arise.

A Comparison of Prognostic Factors in a Large Cohort of In-Hospital and Out-of-Hospital Cardiac Arrest Patients.

We investigated independent factors predicting neurological outcome and death, comparing in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients. The study was conducted in the mixed 34-bed Intensive Care Department at the Hôpital Universitaire de Bruxelles (HUB), Belgium. All adult consecutive cardiac arrest (CA) survivors were included between 2004 and 2022. For all patients, demographic data, medical comorbidities, CA baseline characteristics, treatments received during Intensive Care Unit stay, in-hospital major complications, and neurological outcome at three months after CA, using the Cerebral Performance Category (CPC) scale, were collected. In the multivariable analysis, in the IHCA group (n = 540), time to return of spontaneous circulation (ROSC), older age, unwitnessed CA, higher lactate on admission, asystole as initial rhythm, a non-cardiac cause of CA, the occurrence of shock, the occurrence of acute kidney injury (AKI), and the presence of previous neurological disease and of liver cirrhosis were independent predictors of an unfavorable neurological outcome. Among patients with OHCA (n = 567), time to ROSC, older age, higher lactate level on admission, unwitnessed CA, asystole or pulseless electrical activity (PEA) as initial rhythm, the occurrence of shock, a non-cardiac cause of CA, and a previous neurological disease were independent predictors of an unfavorable neurological outcome. To conclude, in our large cohort of mixed IHCA and OHCA patients, we observed numerous factors independently associated with a poor neurological outcome, with minimal differences between the two groups, reflecting the greater vulnerability of hospitalized patients.

Association between eGFR and neurological outcomes among patients with out-of-hospital cardiac arrest: A nationwide prospective study in Japan.

We aimed to investigate the association between estimated glomerular filtration rate and prognosis in out-of-hospital cardiac arrest patients and explore the heterogeneity of the association. Patients experiencing out-of-hospital cardiac arrest due to medical causes and registered in the JAAM-OHCA Registry between June 2014 and December 2019 were stratified into shockable rhythm, pulseless electrical activity, and asystole groups according to the cardiac rhythm at the scene. The primary outcome was a 1-month favorable neurological status. Adjusted odds ratios with 95% confidence intervals were calculated to investigate the association between estimated glomerular filtration rate and outcomes using a logistic model. Of the 19,443 patients included, 2769 had initial shockable rhythm at the scene, 5339 had pulseless electrical activity, and 11,335 had asystole. As the estimated glomerular filtration rate decreased, the adjusted odds ratio for a 1-month favorable neurological status decreased among those with initial shockable rhythm (estimated glomerular filtration rate, adjusted odds ratio [95% CI]: 45-59 mL/min/1.73 m2, 0.61 [0.47-0.79]; 30-44 mL/min/1.73 m2, 0.45 [0.32-0.62]; 15-29 mL/min/1.73 m2, 0.35 [0.20-0.63]; and <15 mL/min/1.73 m2, 0.14 [0.07-0.27]). Estimated glomerular filtration rate was associated with neurological outcomes in patients aged <65 years with initial shockable rhythm but not in those aged >65 years or patients with initial pulseless electrical activity or asystole. The estimated glomerular filtration rate is associated with neurological prognosis in out-of-hospital cardiac arrest patients with initial shockable rhythm at the scene but not in those with initial non-shockable rhythm.

The Rate of Success of CPR in Patients Suffering from Cardiac Arrest in Patients Admitted in CCU in Cardiology Department Ayub Medical Teaching Institute

Cardiopulmonary resuscitation (CPR) is an essential procedure used to treat patients who are in cardiac arrest, particularly in the Critical Care Unit (CCU). Objective: To assess the success rate of CPR admitted to the CCU, revealing insight on the effectiveness of current resuscitation techniques. Methods: This retrospective study was conducted at Department of Cardiology Ayub Medical Teaching Institute, Abbottabad, between 13th April 2023 to 30th November 2023, 110 patients had cardiac arrest while in the intensive care unit. Data were gathered and examined on patient demographics, pre-existing comorbidities, time to start CPR, duration of CPR, and results. CPR success was defined as a sustained restoration of spontaneous circulation (ROSC) for at least 20 minutes. Results: This study included 110 cardiac patients. Most patients (68.18%) were male. Hypertension was the most common comorbidity at 72.7%. CPR started on average 4.8 minutes late, with a 1.2-minute standard deviation. The average CPR time was 18.2 minutes, with a 5.6-minute SD. After cardiac arrest, 60 (54.5%) patients began CPR within 5 minutes. Another subgroup found 96.0% CPR success in 25 (22.7%) ventricular fibrillation patients. Then occurred ventricular tachycardia (80.0%), pulseless electrical activity (76.0%), and asystole (68.9%). These data suggest that CPR works better in ventricular fibrillation patients. Conclusions: This research sheds light on cardiac arrest CCU patients' demographics, care, and outcomes. The data show that early CPR and ventricular fibrillation detection and treatment improve outcomes for these individuals.

Artificial Intelligence Model Predicts Sudden Cardiac Arrest Manifesting With Pulseless Electric Activity Versus Ventricular Fibrillation.

There is no specific treatment for sudden cardiac arrest (SCA) manifesting as pulseless electric activity (PEA) and survival rates are low; unlike ventricular fibrillation (VF), which is treatable by defibrillation. Development of novel treatments requires fundamental clinical studies, but access to the true initial rhythm has been a limiting factor. Using demographics and detailed clinical variables, we trained and tested an AI model (extreme gradient boosting) to differentiate PEA-SCA versus VF-SCA in a novel setting that provided the true initial rhythm. A subgroup of SCAs are witnessed by emergency medical services personnel, and because the response time is zero, the true SCA initial rhythm is recorded. The internal cohort consisted of 421 emergency medical services-witnessed out-of-hospital SCAs with PEA or VF as the initial rhythm in the Portland, Oregon metropolitan area. External validation was performed in 220 emergency medical services-witnessed SCAs from Ventura, CA. In the internal cohort, the artificial intelligence model achieved an area under the receiver operating characteristic curve of 0.68 (95% CI, 0.61-0.76). Model performance was similar in the external cohort, achieving an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.59-0.84). Anemia, older age, increased weight, and dyspnea as a warning symptom were the most important features of PEA-SCA; younger age, chest pain as a warning symptom and established coronary artery disease were important features associated with VF. The artificial intelligence model identified novel features of PEA-SCA, differentiated from VF-SCA and was successfully replicated in an external cohort. These findings enhance the mechanistic understanding of PEA-SCA with potential implications for developing novel management strategies.

Does ECG monitoring affect resuscitation for neonates with pulseless electrical activity in the delivery room? A simulated, pilot, crossover randomised trial

ObjectiveTo evaluate whether ECG monitoring impacts resuscitative steps during simulated neonatal resuscitation in the setting of pulseless electrical activity (PEA) in the delivery room.DesignThis pilot, crossover randomised controlled trial recruited...

How Did I Manage a Case of Pulseless Electrical Activity During Transcatheter Aortic Valve Implantation in a Patient with Severe Aortic Valve Stenosis with Left Ventricular Dysfunction?

Cardiac arrest during transcatheter aortic valve implantation (TAVI) is rare but is generally associated with dramatic consequences including mortality and severe neurological damage. Our patient is an 89-year-old male with symptomatic severe aortic valve stenosis and left ventricular dysfunction. He had a prolonged cardiac arrest in the form of pulseless electrical activity (PEA) during TAVI. After ruling out cardiac tamponade and bleeding, we decided to do the TAVI while doing cardiopulmonary resuscitation. The hemodynamics of the patient improved immediately after TAVI and we could avoid the use of a mechanical circulatory support. We have also discussed in detail the cause, diagnosis, and management of PEA during TAVI.

Age and its impact on crisis management performance and learning after simulation-based education by acute care physicians: a multicentre prospective cohort study

BackgroundPhysiological changes associated with ageing could negatively impact the crisis resource management skills of acute care physicians. This study was designed to determine whether physician age impacts crisis resource management skills, and crisis resource management skills learning and retention using full-body manikin simulation training in acute care physicians. MethodsAcute care physicians at two Canadian universities participated in three 8-min simulated crisis (pulseless electrical activity) scenarios. An initial crisis scenario (pre-test) was followed by debriefing with a trained facilitator and a second crisis scenario (immediate post-test). Participants returned for a third crisis scenario 3–6 months later (retention post-test). ResultsFor the 48 participants included in the final analysis, age negatively correlated with baseline Global Rating Scale (GRS; r=–0.30, P<0.05) and technical checklist scores (r=–0.44, P<0.01). However, only years in practice and prior simulation experience, but not age, were significant in a subsequent stepwise regression analysis. Learning from simulation-based education was shown with a mean difference in scores from pre-test to immediate post-test of 2.28 for GRS score (P<0.001) and 1.69 for technical checklist correct score (P<0.001); learning was retained for 3–6 months. Only prior simulation experience was significantly correlated with a decreased change in learning (r=–0.30, P<0.05). ConclusionsA reduced amount of prior simulation training and increased years in practice, but not age on its own, were significant predictors of low baseline crisis resource management performance. Simulation-based education leads to crisis resource management learning that is well retained for 3–6 months, regardless of age or years in practice.

Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis

AimPediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion (“BRADY”) vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes. Methods and ResultsProspective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds “immediately” prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min−1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min−1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes. ConclusionsPulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.

Mortality risk factors in patients receiving ECPR after cardiac arrest: Development and validation of a clinical prognostic prediction model

BackgroundPrevious studies have shown an increasing trend of extracorporeal cardiopulmonary resuscitation (ECPR) use in patients with cardiac arrest (CA). Although ECPR have been found to reduce mortality in patients with CA compared with conventional cardiopulmonary resuscitation (CCPR), the mortality remains high. This study was designed to identify the potential mortality risk factors for ECPR patients for further optimization of patient management and treatment selection. MethodsWe conducted a prospective, multicentre study collecting 990 CA patients undergoing ECPR in 61 hospitals in China from January 2017 to May 2022 in CSECLS registry database. A clinical prediction model was developed using cox regression and validated with external data. ResultsThe data of 351 patients meeting the inclusion criteria before October 2021 was used to develop a prediction model and that of 68 patients after October 2021 for validation. Of the 351 patients with CA treated with ECPR, 227 (64.8%) patients died before hospital discharge. Multivariate analysis suggested that a medical history of cerebrovascular diseases, pulseless electrical activity (PEA)/asystole and higher Lactate (Lac) were risk factors for mortality while aged 45–60, higher pH and intra-aortic balloon pump (IABP) during ECPR have protective effects. Internal validation by bootstrap resampling was subsequently used to evaluate the stability of the model, showing moderate discrimination, especially in the early stage following ECPR, with a C statistic of 0.70 and adequate calibration with GOF chi-square = 10.4 (p = 0.50) for the entire cohort. Fair discrimination with c statistic of 0.65 and good calibration (GOF chi-square = 6.1, p = 0.809) in the external validation cohort demonstrating the model's ability to predict in-hospital death across a wide range of probabilities. ConclusionRisk factors have been identified among ECPR patients including a history of cerebrovascular diseases, higher Lac and presence of PEA or asystole. While factor such as age 45–60, higher pH and use of IABP have been found protective against in-hospital mortality. These factors can be used for risk prediction, thereby improving the management and treatment selection of patients for this resource-intensive therapy.